Disease management is a coordinated healthcare delivery program with the goal of improving overall health. As defined by the Disease Management Association of America, disease management is generally a system for coordinating healthcare interventions and communications for people having conditions in which patient self-care efforts are significant. A disease management program typically supports (1) the physician or other clinician/patient relationship and plan of care, (2) emphasizes prevention of disease exacerbations and complications utilizing treatment guidelines and patient empowerment strategies, and (3) evaluates clinical, humanistic, and economic outcomes on an on-going basis.
Many organizations offer disease management programs that provide telephonic contacts to patients diagnosed with a single disease, and provide supporting education materials to those patients. Diseases that have typically been focused on are: congestive heart failure, chronic obstructive pulmonary disease, asthma, diabetes and coronary artery disease (CAD). In general, disease management programs have several components which would typically include: population identification process; evidence-based practice guidelines; patient self-management education (including primary prevention, behavior modification programs, and compliance/surveillance); process and outcome measurement, evaluation, and management; and a routine reporting/feedback loop (including communication with patient, physician/clinician, health plan and ancillary providers, and practice profiling).
Traditionally implemented disease management programs have been telephonic based systems which implement these above mentioned components in successive phases. As an example, a model for implementing telephonic-delivered disease management programs could include a phase for identifying patients who may benefit from the program and creating a target list of those patients, another phase for contacting patients on the list by telephonic and other communication media, yet another phase for enrolling the contacted patient as a participant in the program, and finally a phase for executing patient intervention programs to achieve behavior change and subsequent improvement in outcomes. In a telephonic program, enrollment is based upon a case manager successfully recruiting patients to join the program over the phone.
In the first phase, traditional disease management programs identified patients on certain criteria, which included at least an analysis of the patient's prior claims and medical history. In these programs, the selection of patients to be contacted was done by a case manager or a computer system that would analyze certain data to determine eligibility without personal knowledge of the patient from prior relationship (i.e. there was no input from the patient's physician to confirm that the patient actually had a disease indicated by the patient's claim data or medical history or the like).
In the second phase of a traditional disease management program, after identifying the patients to be contacted, a case manager would cold call identified patients (i.e., contacts patients they do not know and have no prior relationship with) to recruit them into the disease management program. This contact made by a case manager was impersonal and not based on a relationship that otherwise exists between a patient and his/her trusted physician. Therefore, in traditionally implemented telephonic programs cold calling by a case manager suffers the additional inefficiency of not capitalizing of the relationship between the physician who knows the patient and his/her medical history (i.e. the trusted clinician) and the patient to successfully recruit patients to join the program over the phone.
In the third and fourth phases of the traditional disease management program, the contacted patients who agreed to join the disease management program underwent assessment and were enrolled in the program. Thereafter, a nurse coach would create and administer an individualized patient care plan. Traditionally, in these phases a patient's trusted clinician had no input or minimal input in the preparation and updating of the individualized patient care plan.
Theoretically, in a traditional disease management program, the cold calling in the second phase could result in the patient recognizing the need for care and opting to enroll into the disease management program associated with the case manager. In addition, theoretically, the lack of input from a patients trusted physician in the fourth phase may also be harmless in terms of the effectiveness of the care plan developed for the patient. In practice however, traditional disease management programs have not been entirely successful because, (i) the correct patients are not always identified due to discrepancies between a patient's actual condition and the diagnosis codes, (ii) only a small percentage of patients initially identified as potential participants join the program and even fewer continue to remain in the program, and (iii) a patient may end up following a care plan that is rigid and not personally tailored for his/her needs thereby reducing the chances that the patient will continue to stay with the program. For example, a patient's claim data may show a diagnosis code for diabetes making him/her an ideal candidate to be contacted by the case manager. In reality, however, the patient could simply have an incorrect code showing up in the report—a situation which a computerized system or a case manager not knowing the patient would not catch. As a result, this patient would be added to the target population to be contacted for enrollment, but would not be enrolled in the program because he/she did not have the disease suggested by the diagnosis codes. This failure to successfully target the correct patients leads to contact and enrollment inefficiencies. Similar inefficiencies result from the failure to recruit a diseased patient when the patient fails to enroll because he/she is contacted by a stranger who is not his usual or trusted clinician. Other inefficiencies also result from the failure to include the trusted clinician's knowledge of a patient's medical history to prepare a care plan for the enrolled patient.
These inefficiencies and failures are evidenced in traditional disease management programs. Although there is some variation in the efficiency levels at each of the four phases of a traditional disease management program on a vendor and program basis, an industry estimate is a 50% success rate at each phase. Starting with 100% at the beginning of phase 1; 50% of the target patient population is successfully contacted by the completion of phase 2; at the end of phase 3, 50% of contacted patients agree to become program participants by enrolling (also called opt-in); and at the end of phase 4, 50% of enrolled participants exhibit measurable behavior change, which ultimately drives improvement in disease outcomes. Thus, the cumulative efficiency, or engagement rate, at the completion of the target patient identification, contact (outreach), and enrollment phases is 25%, or, one out of four patients on the target list enroll in the program. At the final phase this model would expect only 12.5% of the originally targeted patients to actually exhibit behavior change.
Therefore, there is a need for a disease management program that overcomes the inefficiencies of the traditional disease management program and improves the measurable outcomes of a target population by improving the effectiveness of the intervention. There is a further need for a disease management program that leverages the relationship between the patient and a trusted physician/clinician to improve the effectiveness of a disease management program.